Robotic-Assisted Transcystic Endoscopic Common Bile Duct Exploration

CHAPTER 1

My name's Josh Winder. I'm a general surgeon. I specialize in minimally invasive surgery, so robotic surgery and therapeutic endoscopy. I work here at Penn State Health in Hershey, Pennsylvania. I've been here about five years, and truly my passion is endoscopy and minimally invasive surgery. I think providing patients with cutting-edge techniques, it gets them out of the hospital faster, it decreases morbidity, and certainly increases patient satisfaction. This is a 63-year-old man who has gastric bypass anatomy. He had a Roux-en-Y gastric bypass some time ago. It was done laparoscopically, and he was at an outside hospital because he was jaundiced and was having right upper quadrant pain. There they did some imaging. They saw that he had a dilated biliary tree and what looked like a distal common bile duct stone. So because of his bypass anatomy, they couldn't do an ERCP, so they decided to place a drain in his gallbladder, hoping that it would just decompress his whole biliary system. It did initially a little bit, but unfortunately the drain seemed to have backed out and was draining into his abdomen. So he re-presented about 10 days later with abdominal pain, worsening jaundice, fevers. They did an image that showed now he had free intra-abdominal fluid, which they were unclear about, and because of that they sent him here. He arrived here on the medicine service about a day and a half ago. They got us involved yesterday. And I said, "We probably need to explore this guy." It looks like he has distal common bile duct stones, and in a bypass patient, there's only a few ways to take care of that. One of them is an EDGE procedure, where GI will place a stent through the pouch into the remnant stomach and then through that do their regular ERCP. Another option is to have IR place a drain percutaneously through the biliary system, as long as it's dilated. It's called a PTC drain, where they can then decompress the system, which is kind of a temporizing measure. Last options are to surgically explore, so I opted for that. I thought that was probably the best option, particularly in light of the amount of ascites that he had, the free fluid, which in my mind was probably bile that was spilling out into his abdomen since the drain wasn't adequately controlling it. The plan is to go in laparoscopically. We're going to use a robot this time. Assess everything, take a look at everything, see where the drain is, see if it in fact is bile, and then do a cholecystectomy. Once we get our critical view of safety, once we see the cystic duct and the cystic artery, then we'll make our ductotomy and perform a cholangiogram and assess whether there are in fact distal stones on our cholangiogram. If there are, we can intervene. So my plan is to place a wire down through the cystic duct, pass a scope over the wire, then either use baskets to retrieve the stones or use lithotripsy to break up the stones and flush them down. Once we've done that, we can finish our cholecystectomy. If I can't do that, another option would be to do a transgastric ERCP. So in that case, I would identify his remnant stomach, pull it up against his abdominal wall, and then have my colleague or GI come in intraoperatively and perform an ERCP through his native stomach. To assist that, I'll pass a wire antegrade through the duct. They can then rendezvous with that with their side-viewing scope. Lastly, if we can't do either of those things, we've got to drain him somehow. We've got to decompress that biliary tree. So my plan would be to try and get a wire down through the duct past the ampulla, place a stent across it, and then pin his stomach up against the abdominal wall, the remnant stomach, put a G-tube in if I can. That way we can go back and do an ERCP. I know that he's decompressed because of my stent. Still have the option to do an ERCP down the road. So in this case where we know he has altered anatomy, we know he has bypass anatomy, so that's gonna be off the table. However, none of his biliary anatomy should be altered. All of it should be native. It should be normal. I imagine he's gonna have a fair amount of inflammation. This has been going on for some time. On the scans that we have, it looks like the gallbladder's inflamed, everything's dilated, so we know the cholecystectomy portion of it is, it's gonna be difficult. It's gonna be inflamed. It's gonna be bloody. We know that. But as long as we can delineate his anatomy clearly, we should be successful in doing this all in one take. That's really the goal for this patient. I think it's gonna decrease his overall morbidity, it's gonna decrease his hospital stay, it's gonna decrease his trips to the OR procedure suite to get his duct ultimately clean, and honestly, I think it's a great option for bariatric patients, for bypass patients.

CHAPTER 2

Incision. Knife back. Got it? I haven't seen any fascia at all. There we go. That looks fascioid. Some muscle there. Uh-huh. Posterior layer there. One more. That's in. Behind it. We'll see. All right, grab that camera. Hold onto that obturator. We might have one more little layer there. Why don't you put that obturator back in. Okay. That looks preperitoneal, doesn't it? Mm hmm. There, there we go. That's bow-wow. All right. I'm gonna open this up. Hold on. I figured we'd be seeing fluid, and there it is. We're insulating the abdomen. Yep. See if we can Seldinger in. Lower this camera. Nope. I had the camera in and then it kind of skied. Let's see that obturator one more time. That's in. Hold the port. So taking a view of things, there's definitely some bilious acidic fluid. Here's the drain, kind of just floating in the breeze. I'd like to see that well opposed to the edge of the liver, which it is not. Which is what we suspected. We thought the drain was kind of dislodged and leading to this bilious ascites, which is what we're seeing. So, now that we've got our port in, just taking a look at things. That looks more peritoneal. Agreed. Yeah, he's not very symptomatic. When you're ready, we're gonna need some reverse Trendelenburg. Other way, other way. Yeah, we need him head up. Thank you. Mark, we're gonna have to swing this way over there so that we can bring the C-arm in eventually. Why don't we get our port right here? Well, let's get their lateral one in first and then we'll split the difference with that middle one. This is gonna be an 8, so if that's there, that's there. Once you put one, it's gonna be another 8, getting that falci. Pretty compliant. There you go. Love it. Nice. Why don't you do kind of a suprapubic vertical thing. You want a 12 or 8? This will be a 12. And you got that metal obturator? Good. Yep. Yep. Ease up a little. There you go. Nice. We'll just put an 8 in over here, but we can leave that, so you can leave the gas on, whatever you want, untangle things. He's got a little bit of adhesions over there. Thank you. Okay, should we dock it and see where the chole tube's going through the liver parenchyma?

CHAPTER 3

Let's start with the suction irrigator here and then we'll swap it over to the hot scissor. It's gonna be upper abdomen docking from the right side. Just come in real slow with these two, because they're like real close to bowel right there. We'll make sure we visualize it before you bring the instruments in. That's good. Right there. And then can you rotate the boom a little bit? You can even go a little bit higher with the boom. We'll get there. You got that suction irrigator for me? I'll take it. We'll do fenestrated bipolar in one and ProGrasp in two. Yep. Go ahead and bring that guy in. Nice. Looks pretty good. Let's give it a go.

CHAPTER 4

Well, that's a funny-looking gallbladder, huh? Mark, I would hoist that up with your other hand. I would hoist it up with your ProGrasp in two, and then work underneath it with your fenestrated bipolar. Ooh, there's some rocks. Yep. Yeah. Yeah, you could try that for a bit. And let's suck underneath it. It's your... Yeah, it's the blue pedal. You got it. Is this omentum right here? It is. Yeah. So this is either omentum or it's part of your... Might be pericolic fat? Yeah. I mean, your transverse colon's gonna be up here. Hepatic flexure's gonna be up here, so this is either omentum or it's just part of your... See, this looks like omentum to me, this kind of reaching up in here. Okay. Yep. That's a nasty looking liver, man. Lot of bile. Is this the color of bilious? Yeah. Careful rubbing up against that liver, Mark. You can push that down with your left hand and suck it out with your right. That's, yeah. So this has hoisted up his gallbladder. It looks funny because there's no fluid in it. Usually the gallbladder's got some fluid in it. It looks more like a balloon. This looks all lumpy, bumpy like this because it's full of stones and there's no fluid around those stones. So what you're seeing is all the stones in this guy's gallbladder. We're gonna swap out four for a hot scissor. Zoom out, Mark. Oh, there we go. Good.

CHAPTER 5

It's interesting how fused that looks. Yep. So just taking down some adhesions to gallbladder, trying to get a better view of the fundus and down through the body, down to the infundibulum. Sweep a little bit, Mark. The duo can come up really quickly. Like buzz, sweep, sweep. Yep, yep. Little bit of sweep there. See what brushes down. Yep. Good. Yeah, pretty inflamed and angry. Yeah, you may want to choke down here in a little bit with your number two, just see how it looks. Do you guys have long bullets? You have regular ones? We can try a regular one and see if that'll reach. Yeah, I think you can just, you can come through some of this, Mark. Yep, like you're doing. That's good. It just seemed, like, angry. That's what we're looking for. That's what we're looking for. That could be the vessel, yeah. Try and come off. You're grabbing peritoneum with that bite. Just try and grab gallbladder and see if you can hoist it up medially. Yep. It's all inflamed and bloody. Angry. What are you hitting? Zoom out real quick there. He's got to come under falci. Correct. Yeah, that's falci going down towards liver. It's hanging from the top side of the abdomen. So it looks pretty inflamed, which is what we expected, right? You can actually see here this is his Roux limb going up towards the pouch, which is why we're here. He's got bypass anatomy. He can't get any RCP easily, so we're here to try and do it through a transcystic approach, which, you know, is a lot easier said than done in the best of circumstances, and here everything's all inflamed and horrendous. But our hand was forced because he was spilling bile into his abdomen from this perc chole tube that they had placed at the outside hospital. Zoom out again real quick there, Mark. Let him get that suction irrigator over. There you go. Give me two seconds. I got to work around your arm. Okay. Okay, great. Yep. Yeah, it's just tearing when you put it on traction. You might want to try and get your fenestrated bipolar over there. Mark, I might just leave that spot for a bit, let it tamponade a little bit. Yeah, go real superficial and see if you can clear off some of that peritoneum. I'm gonna be sitting where Mark's sitting here in a little bit. This is looking like it could be it. Good. That's good, Mark. That's good. I mean, it looks like this is turning into infundibulum here. Yeah, we got to take down before we can actually get tension and traction on the posterior wall of the gallbladder. Whether that's artery or not, it's unclear, but that's a pretty decent looking vein going up onto it. This is getting stuck to something. There's this lip of stuff here. You see that? Yeah. Like is this the edge that needs to come down? I think so. I think so. It's getting hung up over here medially. But it's looking like an infundibulum maybe. Things are kind of tapering down. And this all looks like rind. Yeah, rind. Our duct may be under there somewhere. We got to sort out, you know, what's what. That's looking more like peritoneum on this anterior side here, on our side, so we'll keep peeling that. I like using the suction irrigator on these, Ben, because you can kind of clean up as you go. That's looking more like a clear spot down there. He's got a couple little branches here anteriorly. He's got kind of two things going on here, maybe something there, maybe something there. This looks like a node that was bleeding and Mark controlled. That looks like it could be our window behind the artery there. This is not coming down super easy medially. Change our grasp a little bit. Looks like maybe that's where we're getting hung up. Yeah. There's a band of stuff right here that's holding this up. When we fix it, there's a... Cut through this band and just try and bring it down. Yeah, and the same with the anterior stuff there. Let's do it. Yeah, let's swap it out. Come in slow with that sciss, 'cause it was a little low. Okay. You okay? You want me to come out or you can see? I mean, you're good. You're good? Let me see if I can come in with the... Mm hmm. We're sword fighting a little bit. Sorry. It's okay. Something's bleeding right... See if we can get this peritoneum to come down. It's sticky. Mm hmm. Yeah, see this looks like nothing, right? Yeah. This all just looks like rind. Do you agree? Agreed. I think if we just connect the dots from there to there, that'll do it. Mm hmm. Here, maybe it's easier to come this way. Gallbladders, am I right? Gallbladders. The worst. Imagine doing this lap. Yeah, keep that there. Yeah, we could complain to each other even more closely. This looks like... Something. Yep. It's just rind. Okay, nice. It's pretty medial. There's this band right here that I was thinking. This might be a little branch, so I'm gonna take it and do it like this. Make me feel a little better. Great. Things are moving around. Yeah, I think all of this is gonna go. Coming out. Coming in. This is maybe gonna be our window back here. Hmm. I think we're close. We got that leftover rind on the posterior side of the... Right. Right. But I think that's the right place. Because this stuff here, right here, this rind right there. Yep. It's occluded. I can see It's, yep. Pop right through there. I agree. I agree. Let's see if we can work some of this off and see it medially better. Fun. All right. I think that's gonna give us a bit of a view. Now is there stuff in front here? You see how it looks like maybe there's something going this way and then there's this thing in front? Should we take a look? Let's take a look. Yep, that'd be great. Yeah, there's definitely a little bit of bile there. All right, let's take a look. So Firefly, not super helpful. This glows, which is kind of the opposite of what we'd want, right? That node is glowing pretty good. I mean, maybe there's a duct there. Right? All right, I'm gonna swap back. Might be able to grab it better with the fene bi. Let's see. Yeah, just careful on that liver. Yeah, coag up to five. Here I can do it. All right, let's drop it back. You coming back with that suction? Yeah, it's got this thing in front, and I think duct is gonna be back there. Yeah. I think this is... It looks like there might be some vascular stuff in it. It could just be lymphovascular stuff. Yeah, the little tiny lymphatics that are distorting it. I mean, like, I don't know if that whole thing is stranding stuff in front of the duct or if it's just distorting the duct in a weird way. But I can do a little suction. I'm wondering if I'll be able to get underneath that. If I should try and bring it out from over here or just make it bleed. All right, let's hoist this up and out a little bit. This looks to me like... Looking at it more, I think you're right. You think it's just on top of it? Yeah. Yeah. That's kind of what I'm wondering. It's just like going like this. Yeah. We're fighting again. There you go. Mm hmm. Hold up. I can also work on this window a bit more. Keep clearing off this posterior side of the liver, or the gallbladder towards the liver. Uh-huh. Uh-huh. Stay high, like up here. Yeah, stay more on bag. All this char right where I want to be. It's not opening up super well. I could try... Let me take that... I'm gonna take that suction irrigator again, I think. I'm just gonna keep working this space with it. Let me take this guy. We can get the cholangiogram catheter set up. You guys have any questions about that? Hooking up the three-way stopcock, all the things. If you want to just, Ben, if you just want to use that five port and punch it through the costal margin instead of using the angiocath, let's just do that. Try and work this lateral side a bit more, 'cause there's a lot there still. It's coming down a little bit. Yeah, this peritoneum's all gonna go. We'll clear out this side right here. Yeah. Oh, that's really nice. Yeah. Yeah. Again, if we just keep pushing up onto the gallbladder, that'll lift that fine. Yep. Yep. And then even now we can see the cystic duct, infundibulum junction much better. This is all... I think this is gonna be kind of lateral peritoneum attachments, whatever. We got our artery floating in the breeze a little bit more. Yep, that like strand stuff... This stuff is gonna go. And this, we could take all this down. Keep clearing this posterior space. Let me zoom out. You can put that five in. You said you're ready. Bounce there for me. Why is it so bloody? See if you can bring it right here. Was the drain in or out? The drain was mostly out. It's a little bit in. You can see that the gallbladder was decompressed and it was just stones. And was the fluid in the abdomen bilious or no? Very bilious. I've got cholangiogram all set up and ready to go. Great. Yep. Ready for ductotomy. I think we're gonna be okay getting down it with the scope 'cause everything's gonna be super dilated. Okay. Why don't we take that sciss for a minute? Let's see if we can take down some of this peritoneum. My brain's full, Eric. Holy smokes. If my brain is full, can I go home? It is maxed out. It's all right. We're doing okay. Try and hook some of this peritoneum. You see his liver? Pretty sweet. Oh, there you go. So fun. Josh, when your up hand is not, you're kind of out of upward retraction. Now that we've got this dissected, we could probably grab here. Yeah, we could try it. Let's try this for a minute. Let's go back to that suction irrigator in four. That's going to keep opening up that way, Josh, for sure. Yeah. Yeah, yeah yeah, I agree. That nonsense thing there... It's got this thing in front that's super annoying, and I'm trying to figure out what's what. That, I mean, that long spiral, it clearly goes directly to the gallbladder, whatever it is. This stuff. I think the duct is starting about there. I'm not sure. I don't use ICG because I can't see it anyway. The ICG wasn't helpful before. Our node lit up pretty good. That was fun. This stuff here, Josh, I mean, it's pretty heavily stuck, but if you go from the front of the scissors or from the back, if you swing that around, if you swing the gallbladder that way, give you a little backside dissection and that's gonna open up all the way up to about there. But that, yeah, that... This stuff. Let's see. That'll come down. All of this needs to go. Yeah. This thing. There's a window. It's gonna be right there. Do you want like a Maryland, or a Cadiere in that right hand just to grab it and pull it down? Maybe. See if it just peels off. Let's try it. You got a Cadiere? We got a Cadiere. We're stuck a little bit right there, but whatever. All right, let's try the Cadiere in four. I love it. All right, let's see if any of this peels. Oh. Oh yeah. So good. Oh man. The important part here is... Oh, there it is. To not injure something that is critical. And to kind of make progress. Slow progress is still progress. A little stuck there. Slow is smooth and smooth is fast. All right, what does it look like from the other side? What you want to do is take this grossly abnormal, inflamed gallbladder... I do most of my gallbladders lap. Eric doesn't always do gallbladders, but when he does... I don't always do gallbladders. But when I do, they don't look like this. They're all outpatient. Yeah, this thing. What the heck? These are gonna continue to separate, Josh. This is gonna open up more than you might think, and you may want to look at it from the backside again and spin it around. Yeah, dude. Let's do it. There's still this lateral thing is bleeding. Mm hmm. Maybe better. Can you grab it here and kind of take it that way? Let's try it. And then you want to open up right there and there. Yeah. It seems to be opening. You have, there's a little edge right there. This thing. That's the beginning of where you made the window, right? Yep. Your window comes above that. That's just the lip and the backside thing. So to me that's rind. Yeah, I agree. We can come through all this. Come on, now. We got a situation where a robotic port is actually helpful. Right? Get around this crazy angle. They may have a little branch of the cystic artery directly in it that goes to the duct, but it's not, I mean, again, everything in that goes directly into the gallbladder. Let's see. Let's see. We're looking pretty good. There's still this stuff. To me, that's all just infundibulum. I think this is the end of your infundibulum. The beginning of your duct is right there. Somewhere right here. There's probably a small amount of rind on the backside there, but, I mean, if you were to shoot across a cholangiogram where you're grabbing here, I mean, that's certainly a safe spot to make a ductotomy. I think so too. And I think we can get around that pretty easily. Yeah, I mean, I think there's still some schmutz here. I think your actual duct is like back there, and this is kind of rind on top of the duct. But again, I mean, if you do a ductotomy here and shoot a cholangiogram, that gives you plenty of stuff to work with. You know, it depends on how long my cystic duct actually is. Maybe that gives you some more confidence to clear that a little lower if you need it to. Go a little more medial. Try it? Try a ductotomy like right there? Yeah. Maybe hide the bodies first. It's all just back bleeding, you know? It's like... All right, we're gonna be shooting our gram here in a little bit. See if we can get our catheter down there. Okay. That looks a little better. Yeah, I agree. All right.

CHAPTER 6

So let's put a hole in the bag right here. Yep. All right, and that's got a pulse. Less of a pulse. All right, should we try it? Pause for one second. Ready. There's something back in here. All right. So where...? It's coming from back there. And when we lift up on it, we can't see it, but when we flip the gallbladder... Give me that suction irrigator again. Yeah, I also hit some artery in this wall here. So right now I've got my hand on our ductotomy that's got a bleeder in it. Can I get like a Cadiere in my right hand? Let it come off. I think your jaw is in it and your catheter isn't. Yep. I'm gonna advance that catheter a little bit. I'll let you correct it in. Yep. Yep. Just you can back everything out a little bit. There you go. Uh-huh. Great. Nice grab, Ben, because you got not only, not only is that in place, but you grabbed it in the direction that, of that bleeder. Grab that bleeder too. So you kind of do things with one. That's great. All right. You want some saline first? Yeah, yeah. Let's take a look. Okay, we are ready for our gram. We gotta splay out those arms a fair bit. So Ben, right now I'm not on anything on two or four. We can also move three back. One and four, one and four. Two's got the gallbladder. And then we're going to come right over the top through this gap. Yeah, you're good on the head. You're fine. Let's just take a shot and see how close we are. And if not, we can undock one and two and come in from the side. All right, go ahead and take a spot. That's not terrible. Can we spin the image right side up? Yeah. Nice. So we got to go, actually we're a little bit below. We're low. Yep. We need to go this way. Okay. Take a shot there? Let's come back in. Take a shot there. We need to square 180. Yeah. The image needs to be rotated. Where's your Olsen? This is your Olsen clamp right here? That's our Olsen clamp on screen left. Yeah. So I think we're in a perfect position. This isn't bad. Yeah, yeah. All right. You got some contrast? I dropped some contrast. Give me one second. All right, everyone ready? We're going to switch to fluoro. We got a big filling deep like this way. That's a big freaking rock down there. It's a massive rock. But we've got a very large cystic duct. We do. Massive cystic duct. Yep. And we're getting a lot of retrogrades on his gallbladder and not a lot into biliary tree, right? Yeah, but it looks like... Looks like we've got a big dilated cystic duct going down to this big stone. Like this is all big dilated duct. Little bit of backfilling here. Big defect right here. Okay.

CHAPTER 7

Where's our SpyGlass? Oh, it's over there. Are you getting the wire down? Yeah. Okay. Can we unlock the C-arm for a second? We're gonna have to bring it down. And then can you take it a little bit more out of this turn? Out of the rainbow? Yeah, out of the rainbow. Is that what you guys call it? I love that. Yeah. Yeah. It's a fun word. Okay, let's try it there. Okay, I need you to get this IV tubing and pass it off over here over Ben so we can get it plugged in. Okay, I like that. I've got it wire down into duo. Great. Past the rock, huh? Past the rock. Great. Oh, let me get you the lithotripsy probe. We'll plug it all in at once. I feel like it might work better if we have the SpyGlass cart right here. Okay. Do we have the lithotripsy probe? Okay, you want to give me IV tubing? Okay. Let me plug this into this bag of saline. You guys can prime it. All right, lithotripsy probe is plugged in, then we need our pedal for it. All right, you got everything? Yeah, so this is... So now you want to put your sheath down over your wire. There's a blue thing, that's the obturator that goes down through the other side of the white thing. And then blue thing down the back end of the white. You can take your free hand and grab the wire to secure it for him once he backs it out. Hold on. No, no, don't grab our tube. Just, yeah, grab a wire. Grab a wire, good. Grab a wire. Great. Okay, I'm taking out the arm, the side port. Hand me that sheath. Right in front of the case right here. And then we need to switch this monitor over so he's got the SpyGlass view. So switch to monitor one. Go ahead and pump that and flush it till there's water coming out of the tip of that. Yep. Open up. You don't need to go all the way down with the obturator. You got wire? Yeah. Great. Did it come out? Yep. Good. You want me to take this off? Yeah. All right. The other thing that could be helpful here in a minute is securing the sheath instead of the wire. Can you get a color view of that? Can you see through that gap? It's kind of terrible. If you got a wire, you'll get in fine. You want me to let go? Yeah. So look at your scope view, and you'll have to torque the scope around to get it in the right orientation. You can go ahead and give irrigation now. So push some irrigation to clear this view. Now torque it around so that you can get in on the wire. Mark, let go. Yeah, it just keeps... Uh-huh. You may want to ease up on your anterior push and see if you can twist it a little bit better to get it down in. Yep. See how you have to torque it over, like 180 to get it down? Uh-huh. Yep. Good. Okay. So Mark, you're free. You don't have to do anything right now. Yeah, just hold sheath. Yeah. Just don't pinch it too hard. Just hold it a little bit and just kind of secure it. That good? Yeah, that's fine for now. And are we recording this view? Great. Okay. Yeah, keep irrigating. You're doing fine. There's our... Do I see a rock there? I do see a rock. That is a rock. Okay. Okay. So I'm gonna... You want to burn wire? Burn the wire, yeah. Yep. Slow long purchase. So I'm thinking that this is... I'm not sure how many of these rocks are going to pull out or push this way. Do you want to do the sphincteroplasty first? I mean, now that you've got your scope down. Yeah. I can rewire to complete sphincteroplasty. That's our guy right there. Why don't I grab this one first, and start and then the other side? Are you pretty distal right there? I can't... I've got like a minimal view of the screen here. I'm pretty distal, I think. Do you think that'll come out? Why is that weird thing? I don't know. But... Did x-ray leave? That's fine. Hey, what happened with our fluoro? Our images are going wonky for us. Let's give it a shot. I think it might come out. That's not... Did we get a second monitor? I got it. Great. Where's it at? Right here. Okay. Let's put the monitor like here. Okay. What do you think, Josh? I can't see it very well. How big is it? It's big. And there's like some folds there. We like came through at the duct and everything so easily. Yeah. I think we can give it a shot. And if we don't, we break the wire, and then we... Breaking the wire is the worst. It's the worst. What do you think, Dr. Pauli? You think that's the distal stone? I think it's a stone. I only saw one stone there. Yeah. It's pretty far distal, and it was, you know, mostly obstructive. Yeah. I think it's bigger than what you're seeing based off of the fluoro in the... Yeah. Can you get down to it? Did you take your wire out? I took my wire out, but I didn't... You can take the wire all the way out and put it in the sheath. Just make sure you know which side's the pointy side and which side's the floppy side. My concern as I look at this is how are you gonna get a basket even open around it? Yeah, it's mostly occluding. It's mostly obstructive, and you need some room to get a basket around it. You're in such a good position right now. Let's break it. I would just blast that thing to smithereens. Yep. Yep. Yeah, I think it'll break. There you go. Get a little closer. I can hit the pedal for you too if it's too awkward. Irrigate. All right, irrigating. Yeah, that's breaking nicely. Yep. Just like a Tootsie Roll Pop: hard on the outside, nice and soft on the inside. Yep. Nice, Ben. Pull back a little bit. There you go. Pull back a little. And you guys gave glucagon, yeah? Anesthesia, you guys gave some glucagon? Yeah, 80 mg glucagon. Thank you. Yep. If you need any more, let me know, because I can call for it. Okay. I'd just call for it. Okay. There's a clot behind it. You see that? I saw some pink there for a moment. It might just be like mucosa you're seeing. Yeah, it's powered up. There you go. Yeah, keep flushing. Do we have that monitor? Nice. Still black and white, huh? Still black and white, I have no idea what's going on. The other option is instead of using that cable, use the VGA cable. We're gonna use the VGA. That's all I got. This guy that's all the way over on the other side. It's okay. We'll bring it. There you go. All right, let's pop this guy. How's it looking, Ben? Good. Those stones broke up really nicely. Now I'm at ampulla. You can see ampulla? Yeah. Great. I think so. Hold on. Yep. Keep irrigating. Yeah, it looks like clot. I agree. But you agree this is like where it's like ampulla, passing it through? Yep. I agree. That's into, that's going to be shortly into duey. Ben, is there a 5-port in that? No. Oh, I would have left the 5-port and scoped through it. My bad. I see what you're saying. So that... Yeah, you've got one a little bit impacted in there, but I think you'll be able to get it. You can go ahead and give that extra milligram of glucagon. You need another milligram of glucagon? Yep. Oh yeah. You're pushing them through, Ben. I love it. It's 100. Thank you. Ben, is it easier for you to look where you're looking, or do you want to turn your body this way and look at this one? Do you want to...? Neither. Neither. Right answer. I mean, I can bring this one to here, but... Is there any chance it could be... It can't be there, right? It's okay. This is fine. This is working for me, so... So now we're just flushing all the debris down through the ampulla, right? Gonna break all the... See how they're just kind of flying through there as you irrigate? You're doing the surgery, you know that, right? I am? I mean, you handed me the thing, you're flushing them all through. I'm just pushing the pedal here. Yeah, break those bigger bits. This is the part of the procedure, where Dr. Pauli says "Are we doing surgery? Is this surgery?" Break that one. Yep, that's looking nice, Ben. Just keep working those pebbles through. Uh-huh. Just flushing it all down. There's not a great way to cut the sphincter. Now you could do a sphincteroplasty, try and balloon dilate it, which is what Ben was asking initially. It's looking much better. I agree. Just keep irrigating. We just want to blow all this stuff down. This is looking much better, Ben. Little piece there. These stones break up so easily. There's that weird fold you were looking at before, right? Did you give that extra glucagon? Did I ask that already? Okay. Very well. Did we give you a basket yet? You just unscrew the white part from the red part. You don't need to worry about that other piece. And one small stone. This one, you got a huge stone that we didn't think would come through the cystic duct very well, and so now we're breaking it up into much smaller debris, and now we have to deal with all the debris. Some of it'll flush down. Some of it we may end up just sucking out. All of this is looking way smaller. I'm not seeing those big chunks like before. You want to do a basket drag of this stuff? Or do you want to stay down and keep flushing? I think we're still, I think we're still winning. Yeah. So... That's fine. Keep going. Yeah, I'm just gonna back it up just to see what we're dealing with. Yep. Massive depth. Jeez. It's like a mini colon. That's gonna be... I wonder if that was a cystic duct, CBD juncture, like right here where that stone was. Yeah. Yeah. Is that junction there? Probably? Okay. I can't tell. I'm gonna go distal again and make sure this is... The sheath is like in the bag now, which is fine. Just be aware of it. No, it's okay. What do you need, Ben? No, I was just wondering if it'd be helpful to pin the... The sheath? The sheath at a level that, I mean, robotically, could we grab the sheath at all and hold it in place? Yeah, we can try. Sometimes it makes it a little bit harder to get the scope in and out, but we can do that. Is that too tight? No, you're good. That works really nicely for me. Thanks, Mark. Is that clot? Yeah. Yeah. There you go. Yeah, break that one. Oftentimes, I'll bring the boom in from the other side, but this room's kind of hard because they have that separate boom over there. Yeah, you bring the boom in from the patient's left side, set up your SpyGlass at the feet, and it works pretty nicely. That's not exsanguinating, so we're okay. Yeah, it's a decent amount though. Do you want to clean it up a bit? Yeah. Hey, Mark. And then, well, let's do this. Why don't we try a sweep? So you're down there. Oh, yeah, yeah, yeah. Let's drop a basket, sweep this whole duct out, and then I'll suck everything out. Looks like he's bleeding from like his abdominal wall. You see that? Yeah, keep flushing. Yeah, it's coming down from where we put in that port, Ben. Really? Yeah. Okay. Which is why it's bubbling up. Okay, I've got a good setup, I'm gonna come out. Just kind of keep the basket open as you bring it out, and then pull sheath out a little bit as you come back with your scope. Uh-huh. Uh-huh. Great. Yep, bunch of junk. All right, open. We can start to set it all up. Good. Okay, you can close your basket. Close? Yep. Are we gonna need to go back again? Probably. Okay. Hold on one second. Let me give you some scope. You got scope there. Going good. Going down okay? Going down okay. All right. What do you see? It's looks good around, open. You wanna come off a sheath. Is it stuck? Oh, there you go. Good. It's bleeding like along the sheath from the abdominal wall. We'll just need to like suture ligate it when we pull this thing, do like a transabdominal... Back at that weird fold. Okay. Is that ampulla there? Yeah, that's ampulla. I think you're still hot on the probe. You're doing great by the way. Thanks for your help. Yeah, dude. Now slow up on irrigation, because you're going to go back down and try and push 'em through. Now. Now speed it up. That was a nice slow lump. We're getting there, friends. We're getting there. We're winning this game. This the weird fold? Yeah. Okay. I wonder if this is actually production. Could be. Could be. Yeah, that's a great power wash right there. Nice. So then, you know, the question comes up, like, at what point are these little things just gonna pass on their own, right? Yeah. And at what point are you comfortable leaving stuff? It's tough. It's a tough question. I find that so tough. Yeah. I'm so persistent, 'cause getting back here is so hard. Yep. I agree. I mean, for him it's not terrible. Like trying to redo a transcystic is not terrible. He also has dilated that, so a PT... PTC is probably what I would do, is have IR put a drain in and then clear him again. Nice. I haven't seen anything big recently. Me neither. I think we're winning fully. I think so. I think I'm gonna go all the way back and then slowly make my way forward, and then try like basketing the ones that are left. Love it. Yep, I think that's a good idea. Pause, pause. Hold on, hold on. Yeah, let's break this guy up. Break it up? Yep. Unless you'd want to just basket this. Save us from getting all the debris out. Do it. Yeah, just basket it. You guys doing good? Okay. Is that your guy still? Yeah. Okay. You're just getting your basket down? There it is. Open. Flush slowly. Yep. Flushing. Close. Close. I would just trawl it all the way out, man. Can you open again? Yeah, all the way. Leave it out from your scope a little bit. Let me know if you want me to come off this sheath. Hold it open. All the way? What do you got, Ben? It's close. Looks like you're pretty close to... You're like in the cystic duct. Okay. Yeah, I'm gonna go back to where... Okay. Yeah, there's just a little... There's really nothing in it. That's okay. Okay, this is our next, hopefully last look. That's clear, that's like clear. Yep. It's weird-looking. Push. Pushing. There's more pressure. There's still... This is weird. Is there a stone? Like is that all one stone still that we haven't addressed right there? You can pull it up. Flush harder. Flush hard. Yep. Keep flushing hard, keep flushing hard. There you go. That's a better look. Yeah. We've had like probably about 200 cc of blood loss. Okay. You hear that, Doctor? I heard it. There you go. That's looking better. Yeah. It's weird-looking. It's got... It almost looks extrinsic, but then the stone's certainly in the lumen, you know? Yeah, the question is, is this an extrinsic thing or is it cystic duct CBD junction, and we're seeing... Proximal stuff? Proximal CBD stones like impinging on the lumen of the cystic duct. Yeah. Which is weird. It's not a crazy alternative. Yep, see if we can break up some of that stuff, and then we can come back and look at that junction again. Does it seem like all that stuff's going down? All right, stop on the irrigation for a sec, 'cause you're getting bubbles. We're almost done clearing... The duct. The duct. Yep. After that we have to take out the gallbladder, which will take us about 30 minutes. That's going through easy. So come back. That's a small debris, little bit of clot, the take-off. Well, unfortunately there's a big bubble there now. You trying to look proximal? Yeah. Okay. I think you got to try and break that more. Yep. I think it's kind of hanging right at junction there. Yeah, let's get that. You got a lithotripsy probe still? See if you can just break it from this side, slow down on that irrigation for a sec. Okay. Yeah, his abdominal wall is freaking bleeding. Is to manage the- Okay. Problem here. You got run-down of blood there. Yeah, it's from his abdominal wall here. What's this guy's problem? The problem is he has a complete bile duct obstruction, which was incompletely managed by a drain that was basically only half in the gallbladder. Okay? I think when we insufflated we knocked the... So, I mean, your only goal for this operation is to decompress his bile duct, and it doesn't really matter how you do it, okay? That's all cystic duct, yeah? Yeah. If IR can't do it... So go distally. Go all the way down. And then let's convince ourselves that there's nothing big, and everything is gonna pass down. There's a bunch of little stuff. Yep. There's ampulla. We talked about that as an option. Like a laparoscopic-assisted... Just stick a drain back in the gallbladder. You purse-string it in and you call it a day, okay? Pull your probe back. Go all the way down. Yeah, that's passing through. Yeah, that looks good. Okay. Happy? Yeah. So far. Let's keep coming back. I don't think... I tried it a couple times, but I don't think I'm gonna be able to retroflex the whole thing.

CHAPTER 8

I don't think so either, but we can shoot a gram. Yeah. We're gonna shoot a gram of it right here. I can go shoot it for you, Ben. Okay, you've got your Omni. Close up that valve line just so it doesn't leak out. Up top, you guys got lead? Why don't you go ahead and take a spot? Yep, still looks pretty good. Actually, let me get that arm out of the way. Okay, everyone who has lead, wants lead, and has lead? Great. All right, shooting gram. There. More Omni, please. There's something going up that left system. But did you see his pancreatic duct filling? I believe so. Right there? Pancreatic? There's something really... Is that something really distal? This stuff? No, even... Can I get full strength? That's not anything right there. This? Even distal to that. That little... This stuff? Yeah. That's nothing, right? It might be just some little debris things. Yeah. Are we autosaving? Yeah. But it's doing like negatives. I think you're just coming out so quick we're not getting a reasonable proximal view. Yeah. Are you paired? No, this one doesn't pair. We can do it. We can. We got a robot bed, but... Maybe do a little bit of head down and burg and try and get the contrast to go up. Okay. We can try it. We're gonna have to pair the bed with the robot. Can I get more contrast, please? Take out arm four. Have you heard that? You can take out arm four. Can you flip it so it's no longer doing this reverse mode? Looks better. Who wants lead has lead? Yeah, why is it doing that? Do you want it... No. No? Because then, he's hitting the wrong pedal. Which pedal are you hitting, Ben? The left-sided pedal. Don't hit the one with the plus on it. Don't hit the one with the plus on it? This does not have the plus on it. Why don't you, do you need... Why don't you hit it on your end? You can go ahead. Go ahead. Switch it on your end. Go ahead. That's better. Yeah. You can see the trifurcation there intermittently. Yeah. Yeah. Yeah, that's not bad. Okay, that's good. What do you think? I would scroll through one more time with the camera. Yeah. Make sure it looks okay. I agree. Go down distal. You got clear and obvious flow. If you got a couple tiny little flecks there... It should go through. They should go through on their own. Yep. His ducts are massively dilated. If the gallbladder's out, the next target is just a perc drain. Yep. Got all the bile in his abdomen. They shouldn't give us a hard time about doing it. Anesthesia said they wouldn't 'cause he had ascites, or IR wouldn't. Got it. That looks pretty good. Yeah, I'm happy with that. You happy with that? Yeah, I think all this stuff looks pretty small. Keep coming back slow. It's all trash. Yeah. He's in cystic duct now. They're all flecks. They're tiny flecks. Okay. Yeah, it looks good. Yeah, let's do that. Mm hmm. Great. That looks okay. It's reasonable. We'll get it hoisted up, we'll clip the duct, clip the artery, and carve the rest of this thing out. Okay, all yours. Okay.

CHAPTER 9

All right. Let's grab... See if we can hoist all of this up. Let's get that suction irrigator real quick, and then we're going to take clips in four, make sure we're happy with our view, and then we'll clip everything. Look at all this debris you got out, Ben. Okay. Why don't we go... Let's get our fenestrated bipolar back. Hold on. Let's get this. All that is no longer in his duct. Okay. Why don't we get our fene bi back in one. Okay. Yep, we'll take a clip applier in four. Okay. Well, that's cute. You happy with that? I can't see on my screen. Yeah, I'm happy with that. Yeah. Me too. All right, we'll take another clip. Okay. We'll take one more clip. Okay. Let me give you a clear window. Yep, we'll take another. Okey-doke. Let's take a scissor in four. That's what we need. Get behind. Okay, that's duct there, there's clip there. Agree? Yeah. Thick. Whew. Okay, let's get a quick suction irrigator maybe, and then we'll start peeling this all off. Super fun. Fenestrated bipolar in two, or in one, sorry. And then we'll see if we can start carving this thing off of the liver.

CHAPTER 10

Maybe try and carve it out from this. Nope. Wrong one. Moving around. Are you doing stuff, Ben? Yeah, do you want a suction in there or no? Yeah, that'd probably be helpful. Oh, hold on. Let me give you a view. All right, yeah, maybe if you suction down and I stay up we can work together a little bit. It is. It's on the bag itself. Nothing. Let's see if we can find a plane somewhere. Mm hmm. That might just be in bag. Can you suck there for me, Ben? Mm hmm, mm hmm. We can always just leave the back wall a bit. That's what I'm wondering. We should just take this... Yeah, Ben, that's a little better. It's a fun thought. Yeah, I think I agree with Mark. Maybe one of those. Want a drain? Yeah, probably would drain. Yeah, I'm wondering if I just drop two down a little bit towards this. I'm hoisting it up so hard right now. Maybe something like that. Thank you, Ben. Try and get that arm up and out of the way so I can work underneath this. There we go. We're gonna do a top-down approach. Mm hmm. Little bit in the wall right there. See if I can get back in the right plane, hopefully. That's our PTC or our perc chole tube coming into it. Not quite. Thanks, Ben. That's into wall. That's all right. We'll keep working this side as far as we can. Yeah, it's probably about that time. Do the drain? Yeah, I cut the drain. You see the sutures? No. There should be at least just one single loop that comes in, and... See that? That's the other one you have to cut. This one over here? Yeah, that's the one. Yep, perc chole tube's out. Ben, I can try and readjust my number two, because I think we're kind of sword fighting a little bit. We've almost connected the dots here. Great. Little bit of wall there, but I think we got most of it. Oh, that's something. Let me get that with the fene bi. Got it. Wanna just get the gallbladder out first? Yep. All right. All right. Yeah, why don't you suck some of that?

CHAPTER 11

Irrigate there for me. I can clip below it and above it and then just toast it. A figure-of-eight or something? Yeah. Yeah. It was like deeper than a skin bleeder, but not so deep that it... All right, let's see. Something like that? I think so. I can't really... I mean, it's gonna be kind of through it with the tip of this thing, but we'll try it. Oh, great. I don't know if this is going to work, Ben. You can take that clip out. Is he breathing? Is that why I keep getting waves of fluid in my field? Yeah. You have to cut it and do a strip? Where are we at, Ben? What are we doing? TachoSil being opened right now. Okay. Coming in. All right, looking back at the fossa. Oh, that 8-assist you got over there? Okay, what side needs to go against what? Other side down. You guys have used this way more than I have. This doesn't make me feel great. Can I get the butter to stick? Yeah, maybe. Hey, look at that. This is like, yeah, this looks like a corn on the cob, man. Hey, can I get some other grasper in four, the Cadiere or something? Don't stick to my instruments. Why don't you give me a suction in one? I'll try and suck the top side of the liver. We're gonna bring our drain in. We'll probably bring it in through one and kind of lay it up there. Can you give me my fenestrated bipolar in one? I'll tell you when I'm ready for it. You can stop it there. Yep. Thank you. All right, maybe if you can tuck this thing up there. That definitely looks better. Yeah. I think we're good.

CHAPTER 12

Okay. Am I clear? Doing okay?

CHAPTER 13

You got a Carter-Thomason? You guys grabbed a drain, yeah? Yeah, I have one. Okay. Why don't you guys cut down the length of it a bit? Great. Good. So Mark, why don't you take a Maryland or something and put it in through that lateral port? Yep. Then you're going to grab the drain from Ben as he feeds it through. Here's the end of it. Yeah, cut off... No. No. Cut off to like there? Yeah. Yeah, yeah. Don't you want to put it here? No. You want to feed... So he's gonna feed that. Yep, that end through there. Okay. You're gonna want to grab it. You're gonna try and grab it like with one jaw in it and the other jaw outside of it. And then you can pull it out through your port. Uh-huh. Great. And you're feeding it down. Here. Ben, there you go. Thank you. That looks pretty good. Yeah. Yeah, I like that. You have a drain stitch? 2-0 nylon? Yeah. Great. Oh, is that a 12? I though it was an 8. I thought it was an 8 too. Turns out it's a 12. Just don't bag the epigastrics up there. So you can hold the drain for him. As he's wrapping things around, it'll make his life easier. So getting the drain in place now. Next thing we're going to do is get the gallbladder out, and then because we used a couple 12-millimeter sites, in order to minimize the risk of hernia we have to close those, and it's easiest to do laparoscopically. Yeah, 30 on each side. So we're just doing some local in his abdominal wall now just to numb things up. Oops, sorry. Good. So he's stretching out the fascia 'cause the gallbladder's too big to come out, which is another reason why he's gonna close it with some suture once he's done. Some big old rocks there, Ben. See your finger in there. Yeah. You want to feel that? Take a feel of it. Feel all the stones in it.

CHAPTER 14

3-0, 3-0, 2-0. We got number one PDS? I don't know, just give him one of those. He won't know the difference. Yep. Yeah, yeah, yeah. Sneak in there. Let this guy sneak by. Specimen's gallbladder and gallstones. Since we made a larger incision on the fascia to get the gallbladder out 'cause it was so dilated with stones, we're closing up that incision now formally so that he doesn't get a hernia there. What do you guys want to do with this Foley? I'd keep it tonight. Yeah, don't close the perc site. Close that one. Yep. Might wanna help him. That's the one that bled like crazy, so don't yank on that too much, 'cause you don't want to unleash all that bleeding again. If you actually want to just do some nylons up there just to close it, that's fine. Well, you know, a lot of that irrigation we use is probably going back out through the cystic ductotomy. What'd you say? Is all the skin closed? All the skin's closed. Okay. Good work, team.

CHAPTER 15

So it was a difficult case, absolutely, and we expected that going into it. Things were inflamed, things were thickened. Initially when we got in, we saw bile. Like we saw a ton of bile in his abdomen. So, when we looked over the drain, it looked like the drain was somewhat dislodged. You would expect to see the liver up against the abdominal wall where the drain was coming through. We could clearly see the drain, so we knew that that was probably the source of his bile peritonitis and why he was feeling as crummy as he was. As far as the cholecystectomy, I mean, fortunately it wasn't so inflamed that we couldn't see our structures. We could find the cystic duct, we could find the cystic artery. That was great. Once we made our ductotomy, we were able to get down the duct, and I think a big part of that was because of how dilated everything was. I think it had probably been dilated for some time. So his whole biliary tree, including his cystic duct, was dilated. We used a wire initially to get our scope down, but as you saw multiple times after that, we could easily get the scope down because of how dilated the duct was. Sometimes when things aren't as inflamed or when they aren't as dilated, it's much more difficult to get the scope down, and I would use a wire every time to get the scope down if you're doing multiple passes. In this case, it was nice and dilated, so that part of it was pretty straightforward. Once we got into the duct, we could see multiple large stones. We knew we weren't gonna be able to remove those with just a simple basket because of the size of the cystic duct, so then we were committed to lithotripsy. We asked anesthesia a few times to give glucagon to try and open up the ampulla so that it was easier to flush some of that stone and debris downstream, which you saw, but there was still some debris in the duct that we ended up just pulling out with the basket. That takes a lot of time, unfortunately, making sure that all of that duct is clear enough that there aren't any large pieces that will cause an obstruction down the road. So that took a decent amount of time. You saw that we were so focused on what we were doing endoscopically that we missed a skin bleeder or an abdominal wall bleeder that was bleeding out onto the side of the patient. Once we kind of got the lights on and looked around, we could see a fair amount of bleeding from that spot that we had to control in an open fashion. Once that was under control, we were back to performing our cholecystectomy. We'd cleared the duct, we performed our cholangiogram. We were happy with how everything looked. Then it's controlling the cystic duct, controlling the cystic artery like you normally would. You saw the gallbladder was very friable still. The planes weren't super clear, but we were ultimately able to do it in a dome-down fashion. So sometimes when I can't find the plane clearly posteriorly and I'm worried about injuring things, I'll start at the top and just do a dome-down dissection. And that actually worked out pretty well in this case. Once we got that out, there were a few more places of bleeding that we needed to control, which we did. Finally, we irrigated, washed things out, got his gallbladder out. His gallbladder was so dilated with stones you saw we had to open up the extraction site and then close that in an open fashion as well. I ended up leaving a drain. There's controversy behind that. I was happy with my bleeding control, I was happy with my clips on the duct, but I think in this case where it was prolonged, we got into the gallbladder so there was some spillage and bacteria and things, leaving a drain is probably not gonna be harmful, and if anything, it could point us to a problem down the road, if there is a bile leak, if there is ongoing bleeding, in which case we've got that safety valve. I wouldn't leave a drain if I was worried that things were still bleeding. I would control the bleeding before I left the OR. So some people say, "Oh, just leave a drain and you'll know if it's bleeding." Problem is drains aren't great at showing you if it's bleeding because they clot off, and then you can still have intra-abdominal bleeding that's not coming out of your drain, and you can be falsely, you know, feel falsely safe or falsely reassured that things aren't bleeding when in fact they are. Similarly, if there's an obvious bile leak, or I didn't have control of the duct appropriately, I would absolutely try and do that so that I'm not coming back and dealing with a bile leak in a patient that has altered anatomy, right? If you have a bile leak in a patient with normal anatomy, doing an ERCP to decompress the system will help, making sure it's adequately drained with a percutaneous drain. That'll usually get you out of the woods. But in him, we can't get back for an ERCP, certainly not easily, and so making sure we have good biliary control is essential. So in my mind in this case, I don't think leaving a drain is gonna cause harm. It's also going to allow all of that extra irrigant and bile that was in his abdomen to drain out through our drain that I wasn't able to irrigate out and suction out with the robot, so I think it was the right move. So for him, we're certainly going to be following his labs. We want to make sure that we didn't lose too much blood and he's symptomatic from it. His T bili is super elevated. He was like 17 today, so we're going to watch that trend down. Honestly, as long as everything's controlled, which we think it is as far as bleeding and bile leaks, next up, we're gonna start him on a diet, and then we're gonna make sure that all those labs are trending appropriately. I don't expect he'll be in the hospital for much more than a day or so following the surgery. Had we converted to an open procedure, the morbidity would have gone up. I don't know that it would have helped much with what we were doing and how things were going, but he would have been in the hospital much longer because of just the pain and morbidity from that large incision. So I think struggling through it to stay laparoscopic, or robotic in this case, I think it's gonna result in a better outcome for him. It's gonna result in less pain, less wound morbidity. He's gonna get out of the hospital quicker. And again, I think doing everything in one go, meaning clearing his duct and taking out his gallbladder, it's absolutely gonna save him time and money and morbidity down the road.